11
M. Korenkov (ed.), Bariatric Surgery,
DOI 10.1007/978-3-642-16245-9_2, © Springer-Verlag Berlin Heidelberg 2012
Adjustable Gastric Banding
Michael Korenkov , Wendy A. Brown ,
Andrew I. Smith , Leonid Lantsberg ,
Thomas Manger , Rishi Singhal , and Paul Super
2
Introduction
Gastric banding is one of the so-called restrictive pro-cedures in bariatric surgery. The aim is to limit the size of the stomach to a small pouch, which is created by tightening the gastric band (Figs. 2.1 and 2.2 ).
At fi rst the idea of restricting the size of the stomach was carried out by performing gastroplasty. This pro-cedure however was irreversible and the laparoscopic procedure faced major technical diffi culties. Also the band was not adjustable, which is why this procedure is hardly performed anymore and has been replaced by adjustable gastric banding.
M. Korenkov (*)
Abteilung für Allgemein- und Visceralchirurgie , Klinikum Werra-Meissner, Akademisches Lehrkrankenhaus der Universität Göttingen ,
Elsa-Brendström-Straße 1 , 37269 Eschwege , Germany e-mail: [email protected]
W. A. Brown
Australian Centre for Obesity Research and Education , Monash University Clinical School, The Alfred Hospital, Commercial Road , Prahran , Vic, 3181 , Australia e-mail: [email protected] A. I. Smith
Australian Centre for Obesity Research and Education. Monash University Clinical School, The Alfred Hospital, Commercial Road, Prahran, Vic, 3181, Australia L. Lantsberg
Surgical Unit, Chairman of Israeli Endoscopic Surgical Society , Soroka University Hospital , Beer-Sheva , 84100 , Israel
e-mail: [email protected] T. Manger
Department of General, Abdominal and Paediatric Surgery , SRH Hospital Wald-Klinikum Gera GmbH, (Teaching Hospital of the Friedrich-Schiller-Universität at Jena) , Germany R. Singhal • P. Super
Upper GI and Minimally Invasive Unit , Birmingham Heartlands Hospital, Bordesley Geen East , Birmingham , B5 9SS , Great Britain
e-mail: [email protected];
Today infl atable adjustable bands are usually cho-sen. A silicone ring with a soft infl atable balloon inside is connected to an access port just under the skin via a small tube. The band is then adjusted by injecting saline through the port. The most popular bands are the Lap-Band (Allergan) and the SAGB (Ethicon) (Figs. 2.3 and 2.4 ).
Frequent problems occur concerning the port (port rotation, leakage, diffi cult injections, pain around the port, exposure to radiation etc.) which is why better ports are developed today or alternatively remote adjustable gastric bands, which are tested in clinical trials at the time (Fig. 2.5 ).
Even though the laparascopic placement of an adjustable gastric band is considered to be one of the simpler bariatric procedures, there still are several technical diffi culties and pitfalls.
The fi rst to place an adjustable gastric band was Belachew (1983). His technique is referred to as the perigastric pathway. A higher rate of intraoperative complications (i.e., stomach perforation) and band-related complications (i.e., slippage or band migration) was observed, however. The method was therefore abandoned in favor of the pars-fl accida approach. There are only a few occasions when the perigastric pathway may be preferable.
Port system Gastric pouch Remnant stomach Connecting tube Gastric band
Fig. 2.2 CT-reconstruction of a gastric band (courtesy of Dr. Ingrid Harth, Radiologisches Institut, Kreiskrankenhaus Eschwege)
Fig. 2.3 Lap-band (courtesy of Allergan)
Fig. 2.4 SAGB (courtesy of Ethicon)
Fig. 2.5 Remote adjustable Gastric band (courtesy of Allergan). (1) A control unit sends energy and information telemetrically to the easyband through magnetic induction. (2) Antenna: mag-netic induction is sent to the antenna, which is connected to the easyband. (3) A microchip saves the adjustments of the easyband
Preparation
Setting, Positioning, and the Surgical Team
The monitor is placed on the patient’s right side, •
either above or below the outstretched right arm. An additional monitor can be placed on the left side (Fig. 2.6 and 2.7 ).
As in every laparoscopic procedure, gastric banding •
also begins with positioning the obese patient cor-rectly. He is positioned in the lithotomy position, with the upper body tilted upward in a 45° angle (reversed Trendelenburg position). Adequate mea-sures to prevent slipping are mandatory.
The surgical team consists of the surgeon, an assis-•
tant holding the camera, a second assistant, and the scrub nurse. A post to secure the liver retractor can be used instead of a second assistant.
The surgeon stands between the patients legs. If •
there is one assistant, he will stand on the patient’s left side, work the camera with his left hand and a grasper with his right hand. If there are three sur-geons on the team, the fi rst assistant can stand on either side.
The scrub nurse stands next to the patient’s left leg. •
If the operating surgeon is left-handed, she can also stand on the right side.
Installation of the Pneumoperitoneum
Many bariatric surgeons use the well-established approach with the extra-long Veress needle (Fig. 2.8 ).
Some surgeons prefer optical trocars that allow visual control of the access to the peritoneum and the creation of the pneumoperitoneum, thereby requiring only a minimal depth of puncture for entering the peri-toneum and gas insuffl ation. They provide a good alternative to the Veress needle. We use the fi ber optic equipped safety needles for the creation of the pneu-moperitoneum more often now, but they are more expensive than the Veress needle (Fig. 2.9 ).
Fig. 2.6 Positioning of the patient for laparoscopic gastric banding Laparoscopy stack 2nd assistant Surgeon 1st assistant Scrub nurse
In some rare occasions an “open” approach is cho-sen. The incisions are placed either supraumbilically or on the left upper abdomen, where some larger inci-sions for the port placement will be performed toward the end of the procedure anyway. These approaches are not suitable for severely obese patients with a BMI over 50, because a comparatively large cut will be nec-essary. A complete insulation is also diffi cult to achieve, which may lead to continuous gas leakage during the procedure.
Place the needle in the left upper abdomen just •
under the left costal margin on the medioclavicular line. Another possibility is the supraumbilical approach via the incision for the camera.
The puncture site in the left upper abdomen will be •
widened after removing of Veress needle and used for the working trocar.
Install a maximum intraabdominal pressure of •
14 mmHg.
In patients with a BMI over 50, this pressure is sometimes not high enough to lift the heavy abdominal wall suffi ciently. In this case, we begin with a pressure of 20 mmHg and reduce to 14 mmHg after positioning the optic.
Positioning the Trocars
Lifting the abdominal wall for the closed approach is diffi cult and sometimes impossible. The abdominal wall is stretched and decompressed in the process, which elongates the distance between the skin and the peritoneum. In some cases the peritoneum cannot be reached, not even with the extra-long trocars. For these reasons we do not lift the abdominal wall from the out-side, but take care to lift it by establishment of a pneumoperitoneum.
Fig. 2.9 Insertion of an optical trocar under visual control Fig. 2.8 Insertion of the Veress needle into the left upper abdo-men under the costal margin
We prefer the approach through the left upper abdomen, because the abdominal wall is thinner here than around the umbilicus and therefore the puncture path for the needle is shorter. This close to the costal margin the abdominal wall is also more “taut” which facilitates the insertion of the needle.
In obese patients with a long distance between the skin and peritoneum, one can lose the “feel” for the Veress needle during placement. In these cases we prefer the so-called double-click tech-nique; after the second “click” the needle is not inserted any further.
Attention: The trocar sites are indicated as seen from the patient’s view and not from the sur-geon’s; the left working trocar is therefore inserted left to the patient’s middle line (Fig. 2.10 ).
Insert the fi rst trocar in the middle line above the •
umbilicus.
Some surgeons prefer fi ve trocars, other use four. •
They are placed above the umbilicus in the upper abdomen, the exact positioning varying from sur-geon to sursur-geon. Basically a high position is distin-guished from a low position.
For the high position place the working trocars •
(both 12 mm) left and right of the middle line below the xiphoid (Fig. 2.11 ). For the low posi-tion the trocars are placed much further laterally and lower on the medioclavicular line just under the costal margin (Fig. 2.12 ). The additional tro-cars (5 or 12 mm, depending on the graspers and the liver retractor in use) are positioned in the upper abdomen lateral to the medioclavicular line.
Some surgeons prefer a so called compact-pyramidal position of the trocars . The additional trocars are placed, similar to the working trocars in the high position, left and right to the middle line, just below the xiphoid. The working trocars are placed much further down (slightly below the optical trocar) medial to the medioclavicular line (Fig. 2.13 ).
Surgical Technique: Pars-Flaccida Pathway After placing the trocars and exploring the abdominal cavity with either an angled or a straight laparo-scopic camera the left hepatic lobe is lifted upward
Right working trocar Left working trocar 12 12 12 5/12 5 Right additional trocar Left additional rocar Camera trocar
Fig. 2.10 Position of the trocars in relation to the patient
We suggest to insert the optical trocar slightly left of the middle line to avoid having to go through a thick ligamentum teres hepatis. In patients with a BMI under 50 we insert the fi rst trocar a short distance left of the line between the xiphoid and the umbilicus, about one third of the distance above the umbilicus. In patients with a BMI over 50, we place the fi rst trocar a short distance left of the middle between xiphoid and the umbilicus to avoid the optic being “too short.”
12 12
12
5/12 5
Fig. 2.11 High position of the working trocars
12 12
12
5/12 5
and to the right with a liver retractor. The stomach is grasped close to the lesser curvature below the cardia and streched to the left. Now the dissection can be performed.
There are basically three different pathways: Pars-fl accida pathway
•
Perigastric pathway •
Combined approach (perigastric/pars-fl accida). •
Today the pars-fl accida approach is usually cho-sen. This pathway was developed by Rudolf Weiner (1997) as an alternative to the perigastric pathway and its high rate of complications (stomach perfora-tion, slippage).
Step 1 – Dissection of the Pars Flaccida
Place the trocars in your preferred position. Grasp •
the stomach through the left additional trocar with a Babcock forceps just below the cardia close to the lesser curvature and pull it to the left. The pars fl ac-cida (the transparent section of the lesser omentum) is now visible.
Step 2 – Opening the Pars Flaccida
Cut into the pars fl accida with a cautery hook •
through the left working trocar (Fig. 2.14 ). Grasp the perigastric fat tissue through the opened pars fl accida, using the Babcock forceps through the left additional trocar and again pull to the left.
Take care not to grasp the blood vessels of the lesser curvature!
Step 3 – Dissection of the Right Crus of Diaphragm
The right crus of diaphragm is now visible. •
Not to be confused with the vena cava! (Fig. 2.15 ).
Fig. 2.14 Pars fl accida
Vena cava
Right crus of diaphragm
Fig. 2.15 Dissection of the right crus of diaphragm and the vena cava
12 12
12 5/12 5
Fig. 2.13 Compact-pyramidal positioning of the trocars in laparascopic gastric banding
Step 4 – Splitting the Peritoneum Along the Medial Edge of the Right Crus of Diaphragm
Now open the peritoneum with a cautery hook close •
by and along the right crus of diaphragm, going caudally. To tense the peritoneum, pull the right crus of diaphragm in the opposite direction with an atraumatic grasper through the right working trocar (Fig. 2.16 ).
Step 5 – Preparation of a Retrogastric Channel
After opening the retroperitoneal space continue the preparation toward the angle of His. You are now between the left crus of diaphragm and the backside of the stomach.
For the blunt dissection use the grasper (right •
working trocar) and the dissection probe (coagu-lation suction tube, left working trocar) (Fig. 2.17 ). To avoid sliding behind the left crus of diaphragm and thereby producing a false tunnel in the poste-rior mediastinal cavity, always hold the instru-ment in the right working trocar parallel to the stomach. We avoid producing a too broad retro-gastric tunnel.
Finish dissection in projection to the right angle of •
His, without cutting the tip of the instrument free
there. Dissection can take place in a practically avascular area. A slight capillary hemorrhage that might occur here will stop spontaneously.
Step 6 – Introducing the Gastric Band into the Abdomen
After dissection the prepared gastric band is •
introduced into the abdomen. This can either be done through the working trocar or the working channel left after removal of the working trocar. If using the trocar, insert a guiding rod into the trocar in the left upper abdomen and remove the trocar. Use the rod to then insert a special 18-mm trocar.
Introduce the gastric band through the “band tro-•
car” (Fig. 2.18 ). Hold the band by its locking area (not by the tube) with an atraumatic grasper and introduce the stretched band into the abdomen.
The introduction of the band can be done in dif-•
ferent ways. One possibility is from the outside to the inside : Dilate the working channel with a cus-tom-made rod. Then push the band, held and stretched with an atraumatic grasper, into the abdomen; fi rst the band itself, then the tube (Fig. 2.19 ). Another possibility is going from the Remnants of the pars flaccida
Dissecdtion line following the right crus
Right crus of diaphragm
Fig. 2.16 Cutting along the right crus of diaphragm Fig. 2.17 Blunt retrogastric dissection toward the angle of His
Do not enter the posterior mediastinal cavity behind the left crus of diaphragm.
Using a 15 mm “universal” trocar from the start saves changing the trocars.
inside to the outside . Here a grasper, preferably one with a stable tip, is inserted into the abdomen through the right working trocar and out again through the left working (or the additional) trocar. This trocar is then removed, leaving the tip of the grasper showing 5 cm above skin level. Now hold the band by the locking area (not the band itself) and pull it into the abdomen. Then return the removed trocar to its place.
Step 7 – Placing the Band
Now place the fl exible dissector into the before pre-•
pared retrogastric tunnel. Dissecting the tip of the dissector near the angle of His free (Fig. 2.20 ). Technical details may vary at this point depending on the brand of the band.
Some surgeons prefer an atraumatic grasper or a dissector with a markedly bent tip to the fl exible dissector.
Implantation of the Lap-Band
We favor the fl exible dissector for the lap-band •
(Fig. 2.21 ). The tip features a slot for the strap of the lap-band. Grasp it between the end of the strap and the beginning of the tube with a grasper and pull it into the slot from the in- or the outside. Then pull the strap up through the slot up to the •
beginning of the tube. This maneuver ensures a safe hold of the strap in the slot; it is kept from falling out while the fl exible retractor is pulled back.
Fig. 2.19 Introduction of the gastric band through the trocar’s canal into the abdomen
Fig. 2.20 Dissecting the tip of the fl exible dissector near the angle of His
Fig. 2.21 Flexible dissector for the implantation of the lap-band Fig. 2.18 Introduction of the gastric band through the “band
Then straighten the tip of the articulating dissector •
and pull the end of the gastric band around the back side of the cardia. Then remove the strap from the slot with a grasper (Fig. 2.22 ).
After removing the fl exible retractor from the right •
working trocar insert a second atraumatic grasper. Close the band with the two graspers. The lap-band features a strap at the end; pull it through the loop of the locking mechanism until it is closed completely (Fig. 2.23 ).
We do not use a calibration balloon for the cre-ation of the pouch. We consider this step redun-dant when using the pars-fl accida pathway, because the gastric band is always located at the same place and can hardly move vertically because the preparation tunnel is very narrow.
Implantation of a SAGB
The implantation of a SAGB differs from the proce-dure for the lap-band in some steps.
Retrocardiac dissection and placement of the band •
is performed with the so-called goldfi nger instead of a fl exible retractor (Fig. 2.24 ).
Insert the string attached to the end of the band into •
the slot at the tip of the device.
Then straighten the goldfi nger and pull the band •
into the retrogastric tunnel.
To close the SAGB, insert an atraumatic grasping •
forcep through the loop of the locking mechanism. Then grasp the other end of the band and close the band. It is not necessary to pull the entire band’s tube through the loop.
Step 8 – Anterior Gastroplication
After closing the band, perform an anterior gastropli-cation to prevent dislogastropli-cation of the band. Suture the anterior wall of the stomach to the anterior wall of the pouch with several single sutures, using nonabsorbable material. In patients with a large fat pad around the gastroesophageal junction the dissection of the serosa above the band can be diffi cult.
In patients with a BMI over 50 we deliberately omit anterior gastroplication, because the procedure is often diffi cult and may lead to serious complications, such as esophageal perforation or hemorrhage from the per-igastric tissue. We believe on the other hand that the gastric band is already secured safely in the narrow preparation tunnel (pars-fl accida approach) and the massive perigastric fat tissue, especially the precardial fat pad.
Fig. 2.22 Pulling the band around the backside of the cardia
Fig. 2.23 Locking the lap-band
For precise placement of the suture hold the gastric •
band with an atraumatic grasper through the left additional trocar close to the locking area. Pull the tube downward diagonally toward the right lower abdomen and hold under slight tension.
Now grasp the anterior wall of the stomach above •
the band with a Babcock forceps through the right working trocar and pull cranially. This way the serosa of the stomach wall above the band can be dissected more easily.
Place four to fi ve single sutures (nonabsorbable). •
The sutures are directed toward the lesser curvature. •
This way up to fi ve single sutures can easily be placed (Fig. 2.26 ). We believe that a more effective way of avoiding slippage can be thus achieved, although evident data are not available yet.
Alternatively the gastric fundus can be sutured to •
the right crus of diaphragm (three sutures on aver-age). Sometimes, however, the stomach is sutured to tightly over the band, which may lead to a persis-tent singultus or shoulder pain.
Step 9 – Implantation of the Port
The intraabdominal part of the procedure is fi nished after anterior gastroplication. The implantation of the port system is next. A careful execution of this part of the procedure is of great importance, as most of the late complications in gastric banding are related to the port system.
The port chamber can be placed on top of the aponeurosis of the rectus abdominis muscle in the left upper abdomen or presternally over the lower third of the sternum. In patients with a BMI under 50, we position the port in the abdominal wall; in patients with a BMI over 50, we chose the presternal location.
A port positioned in the abdominal wall in the wid-ened insertion site of the working trocar is aestheti-cally more pleasing, an additional incision is not necessary. Inserting a cannula, however, is much more diffi cult and is usually performed under x-ray or ultra-sound control. A presternally positioned port is much easier to puncture, but the port chamber is clearly vis-ible and can cause chronic pain in women, if the elastic band of a bra runs over it.
The tube is pulled out through one of the trocar •
insertion sites, depending on the chosen position. We always avoid the insertion site that will hold the port chamber. The tube might tear off due to shear forces resulting from a strong kinking of the tube. For the presternal port position, the tube is pulled out through the left working trocar, for the position in the abdominal wall through the supraumbilical trocar.
Then the incision is enlarged to about 4–5 cm or a •
new horizontal incision is made presternally.
Fig. 2.26 Completed gastroplication
We consider it important to place the fi rst suture on the left side (toward the spleen) as far later-ally into the fundus as possible (Fig. 2.25 ).
Never suture the gastric fundus to the anterior wall of the esophagus. This can produce too much tension, resulting in rupture of the sutures, perforation of the esophagus, and consequent complications.
Insert an atraumatic grasper at the port site and •
move it subcutaneously over to the tube.
Grasp the end of the tube and pull it back to the •
prepared pouch. Fasten a suture to the tube, with which it can be pulled back in place after the port chamber is positioned.
Connect the tube to the port and suture the port •
chamber per hand or with a stapler to the fascia. Take care to fasten the port chamber straight and securely to keep it from tilting later.
After fastening the port pull the excess length of the •
tube back with the suture. Then remove the suture and push the excess length of the tube back into the abdomen with an atraumatic clamp.
There are several different stapler systems commer-•
cially available, depending on the brand of the band. The implantation of the port chamber is done a little faster with a stapler than per hand, but it requires a slightly larger incision. Insert the chamber into the lower part of the stapler. Then position the stapler onto the fascia, press it down slightly, and fi re. The chamber is fastened with the metal clamps in the stapler. So far there are no long-term evaluation data available comparing the fi xation of the port chamber with a stapler to a suture performed by hand.
Surgical Technique: Perigastric Pathway The perigastric pathway has almost completely been abandoned in favor of the pars-fl accida approach today, but in certain situations it can be helpful. We use this technique very rarely in revision procedures after
failed gastric banding, because the technical steps of revision procedures vary greatly, which is why we describe the perigastric pathway as a primary proce-dure for educational reasons.
Dissection begins at the lesser curvature just •
above the fi rst branch of the small curvatur’s ves-sels (crow’s foot). The right crus is not dissected (Fig. 2.27 ).
If a calibration balloon is used, the tube is intro-•
duced into the stomach. Make sure the tip of the tube is inside the stomach by moving it up and down slightly.
Then fi ll the balloon with 25 cm
• 3 of saline and pull
it back to the GE junction.
The tip of the balloon marks the starting point for •
dissection (Fig. 2.28 ). When working without a calibration balloon, begin as far cranial as possible and close to the GE junction. Grasp the upper third of the stomach with the Babcock forceps (left additional trocar) and pull to the left toward the spleen.
Grasp the densely vascularized fat tissue of the •
lesser curvature with the atraumatic grasper (right working trocar) and pull it toward the liver.
Gastric band
Fat tissue
Fig. 2.27 Perigastric pathway, beginning dissection close to the lesser curvature
When planning a presternal position for the port in women, mark the lower edge of the bra beforehand so that the port chamber can be placed below this line. This way chronic pain which can result from pressure from the bra can be avoided.
Fastening the port chamber with a stapler is faster than suturing per hand, but the incision must be 1–1.5 cm larger in order to use the sta-pler correctly.
The crow’s foot is not always easily found, espe-cially not in extremely obese patients. In this case a calibration balloon can be used or the exact point of dissection is chosen by intuition.
When suffi cient tension is established, begin dis-•
section in the avascular zone between stomach wall and fat tissue. Use a cautery hook or an ultrasound cutter.
The dissection tunnel should be narrow (only about •
as wide as the band itself) and run above the omen-tal bursa at all times. After skeletonizing a small section of the lesser curvature, proceed to blunt dis-section toward the angle of His, staying close to the stomach wall.
The slight diffuse hemorrhage that may occur dur-•
ing blunt dissection stops spontaneously. A coagu-lation hook is very rarely ever needed.
After reaching the fat tissue on the opposite side, •
insert a fl exible dissector or a “goldfi nger” into the retrogastric tunnel. Dissect the tip of the instrument in the angle of His.
Continue as above (pars-fl accida pathway). •
Diffi cult Situations and Intraoperative Complications
Troublesome intraoperative situations during gastric banding can result from hemorrhage, anatomic abnor-malities, injury of organs, or diffi culties during dissection.
Hemorrhage
Hemorrhage occurs mostly through an injury of the left hepatic lobe with the liver retractor. Patients with a massive fatty liver (BMI over 50, long standing morbid obesity) are especially at risk. A fatty liver is easily injured by simply positioning the liver retrac-tor or through the retracting force, but the enlarged hepatic lobe makes it diffi cult to get an overview of the surgical fi eld. In an effort to see better, the hepatic lobe is pulled to the right with great force, which can result in deep tears of the liver tissue with massive hemorrhage. It can be stopped using a coagulatory hook or argon plasma coagulation without having to switch to an open conventional surgical approach. These hematostatic measures however prolong the procedure substantially.
To avoid this situation, the liver retractor should always be positioned under visual control. The retract-ing force of the instrument should always be distrib-uted evenly over the backside of the liver. The retractor should always be held parallel to the bottom surface of the liver. Avoid applying high pressure to the edges of the liver during traction.
Anatomic Particularities and Diffi culties During Dissection
The correct dissection of the surgical fi eld can be diffi cult in patients with a high BMI. This is the result of a massively enlargened left hepatic lobe and marked perigastric fat tissue. Some bariatric surgeons do not perform gastric banding in patients with very massive obesity. Surgeons who do not fi x any limits of BMI are confronted with this problem time and again.
A massively enlarged liver lobe is always in the way. A second liver retractor can be helpful here. One Crest of the balloon
Fig. 2.28 The apex of the calibration balloon at the lesser curvature marks the starting point for dissection
At this point a slight diffuse hemorrhage occurs usually, which stops spontaneously. Injury of a blood vessel at the lesser curvature however leads to massive bleeding, which can be quite diffi cult to control. The bleeding vessel must be secured tightly with ultrasound scissors or clips.
We avoid the use of monopolar electricity or the ultrasound scissors within the retrogastric tunnel in order to protect the stomach wall from ther-mal injury.
There is a direct correlation between the patient’s BMI and the diffi culty of the procedure.
is introduced through the trocar in the right upper abdomen, another through a trocar in the epigastrium. An additional assistant will be necessary.
An experienced camera guide is of great impor-tance. A very large left hepatic lobe simply cannot be retracted to the right suffi ciently. To show a surgical fi eld, the camera must be inserted under the liver. The camera guiding assistant must be able to produce a more or less suffi cient image of a small operation fi eld and keep the camera from fogging at the same time.
In rare cases, massive perigastric fat tissue prohibits the identifi cation of the pars fl accida and the right crus of diaphragm altogether. The perigastric approach can be chosen here, but this option comes with a higher risk of intraoperative complications, such as hemorrhage from the perigastric tissue and perforation of the stomach wall. Before choosing the perigastric pathway, every option to perform the pars-fl accida technique should be explored.
Assign an additional assistant. Place one or two •
additional working trocars in the left middle and upper abdomen.
Pull the stomach toward the spleen with a grasper •
(left additional working trocar), holding it proxi-mally close to the lesser curvature.
Insert another grasper through the other additional •
working trocar and pull the lesser omentum also toward the spleen.
Push the lateral parts of the lesser omentum toward •
the liver with the third grasper (right working tro-car) and cut it with a cautery hook through the left working trocar.
Now grasp the perigastric fat tissue (grasper through •
the left additional working trocar) and pull it toward the spleen.
Then the right crus must be identifi ed. If successful, •
use the pars-fl accida pathway, and implant an extra long gastric band.
If the right crus cannot be identifi ed and the pars-fl accida pathway cannot be used, the perigastric approach is chosen as the very last option.
Early Postoperative Complications After Gastric Banding
Injuries of the backside of the stomach can occur with the perigastric approach. The number of stomach per-forations has been reduced drastically by following the pars-fl accida pathway.
A perforation of the esophagus can occur with either technique. It is often discovered only postop-eratively, with grave consequences for the patient. We believe this to be the result of a gastroesopha-geal instead of a gastrogastral suture during anterior gastroplication. In patients with a massive fat pad the anterior stomach wall cannot always be dis-sected. Some surgeons then suture the anterior stom-ach wall below the band to the anterior wall of the esophagus above the band. If the resulting tension is too high, this suture might break and lead to esopha-gus perforation. We strictly avoid gastroesophageal sutures. If the anterior wall of the stomach above the band cannot be identifi ed, we do not perform an anterior gastroplication at all. We do not recommend suturing the stomach wall to the diaphragm, because of the danger of accidentally injuring the phrenic nerve, which can lead to persistent singultus and shoulder pain.
Therapy of a ruptured esophagus varies depending on the symptoms and extent of the damage. A conser-vative therapy (esophageal stent and thoracic drain) may be considered; in other cases a surgical procedure, either laparoscopic or conventional, needs to be performed.
Revision Procedures
Intraoperative complications are very rare in gastric banding, but revision procedures for late complica-tions are necessary more often and remain a so far unsolved problem for this procedure. The procedures are performed either as emergency- or urgent opera-tions (in complicaopera-tions such as slippage or band migra-tion) or planned in cases of a malfunction of the band or inadequate weight loss.
A Water-Soluble Contrast Swallow, Performed Because of Dysphagia Even After Complete Opening of the Band, Reveals Slippage of the Band
Predisposing factors : Slippage of the band is a typi-cal complication after gastric banding, which was very common with the perigastric approach. Weiner defi nes three different types of slippage: anterior, posterior, or combined. The number of cases has been reduced drastically since the introduction of the pars-fl accida pathway and the character of the slippage,
too, has changed. The anterior type is seen in these cases, with a part of the fundus or the anterior wall of the stomach gliding upward through the band. Depending on the clinical situation and the result of the water-soluble contrast swallow, a complete or incomplete slippage is diagnosed. With complete slippage, patients tolerate neither solids nor liquids, everything is regurgitated immediately. The water-soluble contrast swallow shows a complete stop above the band with no entrance of contrast into the rest of the stomach. In an incomplete slippage, a small amount of liquid may pass. The enlarged pouch will often be tilted to the front; the passage of contrast through the rest of the stomach will be slowed (Figs. 2.29 and 2.30 ).
Prevention : The introduction of the pars-fl accida technique has reduced the rate of slippages dramatically, but the problem is not completely solved. Many authors suggest various tricks and ruses to avoid slippage. Some of them are described in the following chapter. Tried and tested techniques to avoid slippage are:
A narrow retrogastric tunnel (not wider than the band) •
At least fi ve sutures for gastroplication (if possible) •
Management : If slippage of the band is diag-nosed, an emergency procedure must be performed because of the danger of ischemia and necrosis of
the pouch. In case of an incomplete slippage, the procedure is to be performed urgently, because an incomplete slippage can turn into a complete slip-page any time.
In slippage after using the perigastric pathway we remove the band and produce completely new tunnel with the pars-fl accida approach. If the band is still in working order, it is reused; if not, a new band should be implanted.
In slippage after using the pars-fl accida pathway we perform an endoscopic reposition of the stomach. Position of the patient, creation of the pneumoperito-neum, and placing of the trocars are done as usual. Preferably the old scars are used for placement of the trocars. If the port chamber was placed in the left upper abdomen, take care to not damage the tube while plac-ing the trocars.
Step 1 – Transection Adhesions Between the Liver and the Lesser Curvature
After placing the trocars identify the tube and fol-•
low it from the abdominal wall to the band. Then cut the scar tissue between the left hepatic •
lobe and the lesser curvature. The amount of tis-sue ranges from small transparent adhesions to thick layers of connective tissue. Several differ-ent techniques can be applied to transect the adhesions. We use an atraumatic grasper and scissors for dissection and cutting and a coagula-tion hook.
Fig. 2.29 X-ray showing anterior slippage after gastric banding (pars-fl accida approach)(Courtesy of Dr. Ingrid Harth, Radiologisches Institut, Kreiskrankenhaus Eschwege)
Fig. 2.30 Intraoperative picture of slippage after gastric banding
Step 2 – Opening the Gastric Band Tunnel and Dissection of the Lock
After removing the adhesions dissect the locking •
mechanism of the band. If the procedure was per-formed correctly before, the lock is close to the lesser curvature.
The band and part of the tube close to it are foreign •
bodies and therefore covered with a fi brous cap-sule. If the band is to be reused, take care not to damage it irreversibly while transection of a fi brous capsule.
Cut the outer layers of the fi brous capsule with •
scissors.
Then open the fi brous tissue with an endodissector, •
until a part of the band is visible.
Now open the capsule completely under visual con-•
trol and dissect the locking mechanism.
Step 3 – Dissolving the Anterior Gastroplication
After opening the gastric band tunnel and dissect-•
ing the locking mechanism dissolve the anterior gastroplication. There are several ways of doing so: Some surgeons cut close to the suture line with scissors. If the band has been in place for several years, it can be diffi cult to identify the suture line; cutting will open the stomach or produce a mas-sive hemorrhage. We open the anterior gastropli-cation with a linear cutter (Endo-GIA, blue cartridge).
Step 4 – Reposition of the Dislocated Portions of the Stomach
After dissolving the anterior gastroplication reposition the dislocated parts of the stomach.
Grasp the tube close to the band with an atraumatic •
grasper (right working trocar) and lift the band. Insert the other grasper (or preferably a Babcock •
forceps) (left working trocar) between the stomach wall and the band, moving upward. Grasp the pro-truding parts of the stomach and push them back under the band. This maneuver is, however, rarely
successful, which is why you should rather open the band and close it again after reposition.
Step 5 – Regastroplication
After repositioning the stomach, perform a regas-•
troplication. The gastro-gastric sutures are easy to place, because the stomach wall is stretched after slippage. After reposition and closure of the band, parts of the stomach can easily be pulled up over the band and sutured to wall of the pouch.
After performing the anterior gastroplication the •
procedure is completed.
Dysphagia: A Water-Soluble Contrast Swallow Reveals Marked Pouch Dilatation
Predisposing factors : Inappropriate eating habits (binge-eating, compulsive eating), insuffi cient after-care, and a too tight band. These factors are often com-bined and result in dilatation of the pouch.
Prevention : The best prophylaxis of pouch enlargement is regular follow-up examinations and timely reaction to signs of inadequate function of the band.
Diagnostic measures : If a pouch enlargement is suspected, perform a water-soluble contrast swallow. An enlargement of the pouch (without anterior tilt of the stomach) with slow passage of the contrast is usu-ally seen in these cases (Fig. 2.31 ).
Fig. 2.31 Pouch dilatation after gastric banding
The operation protocol of the original procedure should be studied carefully before a revision proce-dure. It is important to know which kind of band was implanted in order to plan the following steps.
Management : Pouch dilatation is at fi rst treated conservatively. The band must be opened completely and adjusted after 6 weeks. Patients should be put on a liquid diet to avoid massive weight gain during this period. After 6 weeks the band is refi lled and the patient is followed-up closely. If the pouch dilates again, a surgical revision procedure is indicated (conversion into a gastric bypass or duodenal switch, gastric sleeve resection with or without removing the band or removement of the band without other procedures).
Large Amounts of Food Are
Tolerated, Although the Band Is Filled and Has Been Readjusted, Intermittent “Black” Stool, Gastroscopy
Reveals Intraluminal Position of a Part of the Band
Predisposing factors : The perigastric pathway defi -nitely is a predisposing factor for these complica-tions. Band erosions belong to the past since the introduction of the pars-fl accida pathway. The impor-tance of other factors, such as “band too tight,” “unconventional” band, port infection etc., is not sci-entifi cally proven.
Prevention : These complications can be avoided by choosing the pars-fl accida approach and “estab-lished” band brands, such as the Lap-band or the SAGB.
Management : After diagnosing band migration, the band must be removed. This is followed by another bariatric procedure to avoid excessive weight gain. If this is to be done in one operation, there are in our opinion two possibilities: a distal gastric bypass and the duodenal switch, because the opera-tion fi eld is far away from the migraopera-tion site. We favor the distal gastric bypass, because the procedure is much easier done laparoscopic than an endoscopic duodenal switch. If the bariatric procedure is per-formed later, other techniques, such as the classic (proximal) gastric bypass or a sleeve gastrectomy can be performed.
If the original band was implanted through the peri-gastric pathway, it can easily be rebanded using the pars-fl accida approach.
Technically the removal of the migrated band is similar to band removal in case of a slippage:
After dissection of the fi brous capsule around the •
band, open it to show a part of the band.
Cut the band and remove it from the tunnel, which •
is by now sealed with fi brous tissue; nothing else has to be done here.
We do not position a drain tube after removal of the •
gastric band.
Band Cannot Be Tightened, a Water-Soluble Contrast Swallow Reveals “Pregastric” Position of the Band
Predisposing factors : This situation can occur after using the pars-fl accida-technique (Fig. 2.32 ). Predisposing factors are a high BMI and massive
Fig. 2.32 Gastric band in a “pregastral” position
Some surgeons insist on suturing the band tun-nel and the opening in the stomach wall. We believe this to be impossible and also unneces-sary. The “classic” damage through band migra-tion is situated at the back of the stomach deep inside the band tunnel and cannot be reached without major dissection work. The damage also does not reach the open abdominal cavity, but opens only into the usually rather thick fi brous tissue around the band.
perigastric fat tissue. In very obese patients, the fl exible dissector or the goldfi nger can accidentally be positioned between the anterior stomach wall and the perigastric fat tissue. The tip of the retractor is dissected in the angle of His; the band is positioned and closed around perigastric fat tissue.
Prevention : This complication happens to the unex-perienced bariatric surgeon. Diffi culties of the proce-dure due to extreme obesity, such as excessive perigastric fat tissue, a large left hepatic lobe or a “too short” optic lead to a complicated and confusing situa-tion. The surgeon must be very sure to insert the fl exi-ble dissector or the goldfi nger behind the GE junction toward the angle of His. A calibration tube, inserted into the stomach during the procedure, can be helpful. The wall of the esophagus can be identifi ed during the insertion; the instrument can then be guided around the GE junction.
Management : A faultily placed band does not have a restricting effect and needs to be removed or reposi-tioned. An undamaged band can be reused.
A Water-Soluble Contrast Swallow Reveals Excessive Esophageal Dilatation
Predisposing factors : In some patients with normal band position and adequate adjustment of the band, an esophageal dilatation after gastric banding is seen; a late stage of the so-called gastric band-induced pseudo-achalasia. The main reason is inadequate eating habits; the patient eats much more than can fi t through the adequately tightened band and then has to regurgitate due to esophageal congestion.
Prevention : This complication arises when an unsuitable patient receives a gastric band. There are, however, no reliable criteria by which to decide which patient is “suitable.” The only way to reduce the inci-dence of this complication is consequent and close lifelong monitoring.
If a patient complains about daily nausea and vom-iting, he is to be considered at risk for esophageal dila-tation and must be monitored closely. If everything (band adjustment, counseling, behavior therapy) has been tried and nausea still persists, the band must be opened for a longer period of time or removed altogether.
Management : If the above mentioned conservative measures do not help, a revision procedure is indicated, which can be anything from a simple removal of the
band up to conversion procedures for a gastric bypass or a duodenal switch.
Inadequate Weight Loss or “Band Intolerance”
Predisposing factors : Inadequate weight loss and the so-called band intolerance are the most frequent reasons for late revision procedures after gastric banding. Two groups of patients can be distin-guished: In the fi rst group band position and band function (ease of adjustment) are normal. Patients with band malfunction belong to the second group (diffi cult port puncture, frequent need of adjust-ment, no lasting tightening possible without leak-age, or disconnection of the tube), as well as those with unwanted anatomical changes, such as begin-ning slippage and beginbegin-ning pouch or esophageal dilatation. The two groups are described separately in the following.
Management : The following revision procedures are possible in cases of inadequate weight loss or “band intolerance”:
Removal of the gastric band •
Repositioning of the gastric band •
Addition of another bariatric procedure, such as •
“banded” gastric bypass or a “banded” sleeve gastrectomy
Removal of the band and performance of another •
bariatric procedure, such as a gastric bypass or a duodenal switch
Weight Gain, a Water-Soluble Contrast Swallow Confi rms Correct Band Position and Adjustment Without Leakage
Predisposing factors : The role of a patient history of clinical depression, binge eating, or sweet eating is discussed controversially.
Prevention : This situation is obviously due to the patient’s inadequate eating habits. There are so far no valid criteria available to identify potential “failures” beforehand.
Management : If a revision procedure is indicated, either an addition of another bariatric procedure (such as “banded” gastric bypass or “banded” sleeve gastrectomy) can be considered or the removal of the band and the performance of another bariatric procedure, such as a gastric bypass or a duodenal switch.
Frequent Nausea, Tolerance for Liquids Only, Tight Band, Rapid Weight Gain After Band Adjustment; Repeated Tightening Leads to More Frequent Nausea Again, No
Improvement After Several Repetitions; a Water-Soluble Contrast Swallow Reveals a Beginning Pouch Enlargement
Predisposing factors : These complaints are called “band intolerance.” The factors leading to this condi-tion are so far unknown.
Prevention : We use the rule “under 40, under 50,” meaning that patients aged under 40 and with a BMI under 50 have a better outcome after gastric banding than older patients with a higher BMI. There is not much scientifi c evidence for this theory; it should be tested in a controlled prospective study.
Management : If a revision procedure is indicated, a band removal with or without the performance of another bariatric procedure (gastric bypass or duode-nal switch) can be considered.
Pain and Redness Around the Port Chamber with Clinical Signs of an Infection
Predisposing factors : The development of an infection of the port chamber early after the implantation is usu-ally due to faulty implantation technique without strict consideration of the rules of hygiene or it is due to a postoperatively infected hematoma around the port chamber. If the infection occurs later, the reason can either be a contamination of the port chamber during adjustment or an ascending infection after band erosion. Prevention : The implantation of the port chamber is a very important part of gastric banding, considering that up to 25% of all patients who receive a gastric band need revision procedures because of port-related problems. But it is probably quite customary for the surgeon to leave after the intraabdominal part of the procedure and let the assistant perform the implanta-tion of the port chamber. We recommend to have the implantation of the port chamber done by an experi-enced bariatric surgeon. Careful intraoperative hemo-stasis, strictly aseptic conditions, and the mandatory application of subcutaneous sutures on top of the fas-tened port chamber help reduce the number of early postoperative port infections.
Management : Port infection is a serious complica-tion that requires the complete removal of the gastric band in many cases (Fig. 2.33 ). If the infection occurs late and is due to band erosion, removal of the band is
the only choice (see therapy band erosion). If the infec-tion occurs early after the procedure, there is a chance to save the band. We recommend to remove the infected port chamber, close the end of the tube with a suture and push it into the abdomen. These patients must be monitored closely. When there are no signs of an infec-tion any more or signs of a band erosion, a new port chamber is implanted. The end of the tube is pulled out of the abdomen in a minilaparoscopic procedure and connected to the new port chamber. If the end of the tube cannot be found, perform a laparoscopy to iden-tify the tube.
Port Puncture Impossible: An X-Ray Reveals a Flipped Chamber
Predisposing factors : The port chamber tilts or fl ips over the most often if fastened to the aponeurosis of the rectus abdominis muscle in the left upper abdo-men. Other predisposing factors are fastening the chamber onto fat tissue instead of onto the aponeurosis or using less than four sutures. So far there are no long-term data available regarding the infl uence of stapler systems on the rate of fl ipped over port chambers.
Prevention : We recommend positioning the port chamber presternally in patients with a BMI over 45. Less subcutaneous fat tissue and a more “taut” skin help secure the chamber tightly within the surrounding tissue. The thinner subcutaneous fat layer also facili-tates the even placement of the sutures within the fas-cia. We recommend placing all four sutures within the
Fig. 2.33 Loose port chamber after persistent infection of the port chamber. This patient refused to have a revision procedure for a long time and continued using the port, fastened to the skin with surgical dressing
planned pouch fi rst, positioning the port chamber next and tying the knots afterward.
Management : If the port chamber is fl ipped over, it must be turned back into the correct position in a revi-sion procedure. If it fl ips again, it should be reposi-tioned from the left upper abdomen to a presternal position.
2.1
Surgical Technique by Wendy
A. Brown and Andrew I. Smith
(Australia)
Wendy A. Brown and Andrew I. Smith
Preparation
Setting, Positioning, and the Surgical Team
The patient is positioned in the lithotomy position. •
We use a table with either a buttock support or an adjustable seat as the patient will ultimately be tilted head-up to around 45°.
The legs are supported in stirrups with the knees •
angled toward the opposite shoulder. The legs must be kept relatively low so that when the operator is between the legs their arms and instruments do not clash with the legs.
The surgeon will stand between the patient’s legs. •
The assistant surgeon will stand on the patient’s left and the scrub nurse will be between the assistant and the surgeon on the patient’s left.
The screen and the laparoscopic stack are at the top •
of the bed on the patient’s right, with diathermy also on that side. The leads for the camera and the insuffl ator are secured at the top end of the opera-tive fi eld; the lead for the laparoscopic diathermy comes across to be placed in a sheath on the patient’s right hip.
The post for securing the liver retractor should be •
positioned at the level of the costal margin on the patient’s right.
Betadine is used to prepare the skin. •
The operative fi eld is square draped from the nipple •
line to below the umbilicus.
We do not routinely use suction; however, we have •
it available in the theatre.
We prefer to have a Mayo table behind the surgeon •
so that we may take the graspers we require. We also have a warmer for the laparoscope to be easily accessible for the assistant surgeon.
Our patients will generally have their blood pres-•
sure monitored with a non-invasive cuff on the upper arm. Only rarely is an arterial line inserted. Intravenous access is via a peripheral line.
DVT prophylaxis consists of subcutaneous low •
molecular weight heparin on induction and all patients wear compression stockings. Sequential calf compression devices are used only for high risk patients.
A patient warming device is placed above the •
nipple line.
The anesthetist passes a calibration tube orally that •
will be used to check the position of the band dur-ing the operation.
Trocar Placement and Pneumoperitoneum
We make a 5-mm incision just below the left costal •
margin at a 45° angle from the umbilicus. Further port positions are as shown in the diagram below (Fig. 2.34 ).
We will generally make these incisions prior to •
insuffl ation. If, however, the patient has a deep waist crease or if we are unable to palpate their We pin the hand-held diathermy on the top drape
separate to the camera leads so that it will be retained at the end of the case when other equip-ment is passed off.
We prepare the skin widely from the level of the nipple line down to the pubis in case an open procedure is required.
We do not use “booties” for the leg as we fi nd these impossible to place in a clean manor in the obese. Instead, we use a large drape over each leg and then a drape across the pelvic region.
We choose antibiotics to cover skin and bowel organisms. Most commonly this is fl ucloxacillin and ceftriaxone as a single dose on induction.
ribs, we do not site the subsequent ports until insuffl ation is achieved as we fi nd that we can place them more appropriately once a pneumo-peritoneum is in place.
We currently use a 5-mm optical separating device •
to enter the peritoneal cavity in the left upper quad-rant. This requires a 0° telescope.
Insuffl ation with CO
• 2 is commenced at low fl ow (3 l/min) after confi rming the catheter is in the perito-neal cavity. If the patient tolerates low fl ow, high fl ow (20 l/min) is used for the rest of the case to a maximal intraabdominal pressure of 15 mmHg. The patient is then tilted to a head-up position. •
The 0° laparoscope is changed to a 30° angled lap-•
aroscope which has been warming in hot water. The next instrument placed is the Nathanson liver •
retractor. Using the epigastric incision, a 5-mm tro-car is used to make a pathway. This should enter the patient at a 90° angle to the skin and should be at the level of the liver edge.
The Nathanson retractor is then passed with the arm •
facing toward the patient’s left. After the stem is inserted, it is rotated into place and the liver gently retracted toward the patient’s right shoulder. After the liver is retracted, three further 5-mm ports •
and a 15-mm port are introduced. All are long ports, and are angled toward the hiatus.
Surgical Technique with Hiatoplasty
The camera is placed in port 1. Atraumatic graspers •
are placed in ports 3 and 6.
The hiatus is assessed and if a hiatus hernia is •
known, or if laxity is found intraoperatively, then the hiatus is explored. If no hernia is seen, then the hiatus is not explored and I would proceed to sim-ply opening the angle of His.
In this case, the patient was known to have a hiatus •
hernia. In Fig. 2.35 it can be seen that there is a clear hiatus hernia.
To dissect out the hiatus, the angle of His is dis-•
played by retracting the fundus with the retractor in trocar 6, and esophago-gastric fat pad with the retractor in trocar 3.
Using the hook diathermy, dissection starts at the •
point where the peritoneal refl ection of the esophago-gastric fat pad is clearly at the level of the spleen, above the fi rst short gastric artery. The peritoneum is divided along the line of the left crus.
The left crus is then completely cleared using blunt •
dissection, and the dissection is continued on to the Hiatus hernia
Fig. 2.35 Hiatus hernia
right crus. Once the crura are cleared, the esopha-gus is readily displayed.
An anterior crural repair is performed using 2/0 •
Ethibond in a fi gure of 8 stitch (Fig. 2.36 ).
The pars fl accida is then opened using the hook dia-•
thermy and a point just anterior to the right crus is chosen to start the dissection behind the esophagus. This is usually at the level of a line of fat crossing the base of the right crus.
With an atraumatic grasper, retract the lesser curve •
fat from trocar 6.
A blunt-nosed retractor is passed through trocar 3 •
and is gently advanced in front of the right crus from this point. It should pass easily.
A lap-band placer is then passed through the same •
pathway via trocar 4. It is a curved instrument with a blunt end and an eye at the tip. At the beginning of the passage the convexity should face caudally. As it is gently advanced, it is rotated clockwise, so that the convexity faces cephalad.
The tip of the placer is seen in the angle of His. It •
is essential that the placer comes out accurately at this point.
The placer is then pushed through (Fig.
• 2.37 ). If
less than 2.5 cm of the end of the placer is visible then a larger band size is selected.
The band is primed with normal saline and the end •
of the tubing is cut at an oblique angle before intro-ducing it into the abdomen through the 15-mm port. The tubing is then threaded through the eye of the placer.
The placer is pulled back through to the lesser curve •
side. The tubing is therefore delivered through a pathway behind the esophago-gastric junction, above the lesser sac. By pulling the tubing through along this pathway, the band is placed correctly. Prior to closing the band the position is confi rmed by •
passing an orogastric calibration tube. The end of this tube has a balloon on it. This is infl ated with 20 cm 3 of
air after the tube is seen to pass through the esophago-gastric junction and into the stomach. The whole catheter is then gently pulled back until the balloon lodges at the esophago-gastric junction. The band should be seen to be lying at the equator of this bal-loon. This also allows us to check for hiatus herniae that may have previously been missed (Fig. 2.38 ).
Fig. 2.36 An anterior crural repair is performed using 2/0 Ethibond in a U-shaped stitch
Fig. 2.37 The tip of the placer is seen in the angle of His. If less than 2.5 cm of the end of the placer is visible then a larger band size is selected
Fig. 2.38 Balloon at the end of the calibration tube, fi lled with 20 cm 3 of air
After confi rming the position, the oro-gastric cali-•
bration tubing is removed and the band is closed. We pull the tubing out of the body through trocar 4 and secure it to the drapes with an artery forceps so that the buckle rotates out of the way for suturing. We cover the exposed tubing with a betadine soaked gauze.
The fundus is then secured around the band by a •
series of interrupted gastro-gastric sutures. We usu-ally use 2/0 Ethibond on an atraumatic needle. We use trocar 6 for the needle holder, and use a blunt nosed instrument through trocar 3 as the other sutur-ing tool. I place an atraumatic grasper through tro-car 5 and use this to retract the fundus so that we can clearly see the most lateral point on the fundus. This is where I start my suture line
The suture is completed into gastric tissue above •
the band. If the gastric wall cannot be clearly seen, it is important to retract or remove the esophago-gastric fat pad so that it is well displayed. Otherwise there is a danger that the suture will secure the band across the esophagus and no gastric pouch will be created.
Generally three gastro-gastric sutures are used to •
secure the fundus around the band. Take care to not have these sutures under tension, and the sutures should not impinge on the buckle devise of the band, as these factors are thought to contribute to band erosion.
One suture is placed below the band. This gastro-•
gastric suture apposes the tissue from the medial edge of the folded fundus to the lesser curve – the band tubing is reintroduced into the abdomen and the buckle is rotated to sit in front of the lesser curve. If the band is left rotated, revisional surgery is much more diffi cult. The band tubing is then passed out through trocar 5 (Fig. 2.39 ).
The laparoscopic equipment is now passed off and •
the trocars removed.
The port is primed with normal saline. It is con-•
nected to the band tubing.
The skin incision at trocar 5 is extended, and the •
anterior rectus sheath is displayed by blunt dissec-tion. Often Scarpa’s fascia is very dense at this point, so care must be taken to ensure that the cor-rect layer is displayed. An area inferior to the exit point of the tubing is cleared. It is important that the tubing gently drops into the abdomen. If the angle of entry into the abdomen is too acute the tubing is
in danger of cracking. The port is secured to the anterior rectus sheath with either 2/0 Prolene sutures or with one of the commercially available stapling devices.
Deep tissues are closed with vicryl and the skin is •
closed with subcuticular monocryl. If the patient has a particularly heavy apron, then we will gener-ally reinforce the port incision with interrupted prolene sutures.
2.2
Surgical Technique by Leonid
Lantsberg (Israel)
Leonid Lantsberg
Introduction
Keep it simple and stupid (KISS). As long as you follow the simple principles and rules and avoid doing stupid mistakes, the chances of getting into trouble with this surgical procedure are very little. My pre-ferred technique is the pars-fl accida approach, which is used to overcome the problems associated with the perigastric technique.
Preparation
Setting, Positioning, and the Surgical Team
Instrument requirements: One “Goldfi nger” •
Two atraumatic graspers •
Two needle holders •
A 45° scope •
Suction and electrocautery are needed in rare cases and should be requested only if necessary during the procedure.
The patient lies on the operating table in the “French •
position” (surgeon standing between the patient’s legs), head up 20°–30°, and tilted to the right (left shoulder up) 10°–15°.
A fi ve trocar approach is used (three 10 mm and •
two 5 mm) to obtain pars fl accida retrogastric blunt dissection to create a tunnel for the band.
Have a constant contact with the anesthetist; if the •
patient shows bradycardia, hypotension, or desatu-ration (due to ventilation diffi culties) reduce or defl ate the abdomen completely until the problem is resolved.
Good abdominal wall muscle relaxation is manda-•
tory for achieving a free intraabdominal maneuver environment. In a patient with a “heavy abdominal wall” (highly resistant to insuffl ations) increase the insuffl ation pressure up to 18 mmHg.
Trocar Placement
A Veress needle is usually inserted in the left upper quadrant, but if the patient has a scar from previous surgery, keep away from it as far as possible.
Insert the fi rst trocar for the camera high enough so you can reach the appropriate structures (such as GE junction, crus of diaphragm etc.) usually around 20–25 cm below the xiphoid.
A 10-mm trocar will be inserted next in the left •
upper quadrant in anterior axillary line below 10th rib. This trocar is used for stomach fundus retrac-tion and its inlet is used for band introducretrac-tion into the abdominal cavity in later stages of the operation.
Two 5-mm working trocars are inserted approxi-•
mately at the crossing of the midclavicular and hypogastric lines on each side.
The last 10-mm trocar is inserted through a •
transverse subxiphoidal incision and is used for retraction of the left hepatic lobe by a single grasper and for subcutaneous presternal pocket creation for the port positioning at the end of the procedure.
Surgical Technique: Pars-Flaccida Approach (SABG)
Identifi cation of the left crus is achieved by disrup-•
tion of the gastrophrenic ligament through a small 1–1.5 cm dissection created by a “goldfi nger.”
Now open the pars fl accida just anterior to the cau-•
date lobe of liver followed by the identifi cation of the right crus.
Create a retrogastric tunnel under direct vision by •
using a “goldfi nger” and a needle holder and gently progress toward retro/supragastric fat which is rec-ognized by the typical yellow color.
Only when reaching the fat pad the surgeon will •
bend the “goldfi nger” (the right side assistant should simultaneously grip and pull the fundus downward using atraumatic forceps). The tip of the “goldfi n-ger” should appear superior and posterior to the fundus without any additional tissue on it.
If the patient has a big left liver lobe (mainly males) introd uce a sixth trocar in advance and ask for a second assistant.
Use the length of your palm as a measure for the distance below the xiphoid to the point of the trocar insertion.
The size of the dissection is crucial since a pre-served gastrophrenic ligament is used as a band-anchor, in an attempt to minimize the incidence of slippage.
Rules for the creation of the retrogastric tunnel Gentle, cautious, and powerless smooth •
motions toward the GE junction behind the posterior gastric wall will prevent gastric wall perforation.
The tunnel should be created high enough, •
just above the lesser sac, in order to prevent the possibility of posterior slippage (no need for a gastrostenometer once experience in the procedure has been gained).
